Injury (1992)
23,
(6), 388-390
387
Printed in Great Britain
Percutaneous screw fixation of tibia1 plateau
fractures P. Keogh’, C. KellyI, W. F. Cashmanl, A. J. McGuinness’ and S. K. O’RourkeZ ‘Department of Orthopaedics, Dublin, Ireland
Cork Regional Hospital, Cork and “Department
A seriesof 13 patientswith dispLxedfia&res of the tibia1plateautreated by closed reductionand percutaneouspinning have been reviewed 77 months affer surgery. All fhe operationswere pe@rmed using image infensificafion to aid reducton of fhefra&re by ligamentotaxis and foguide screw placement. In two CASPS, arthroscopy was used in addition to fan’litafeelevationof the ark&r surfacetcsinga probe inset-fed througha wrtical window in the proximal tibkl metaphysis. The postoperative rehabilitationprogramme consistedof early mobilizafionand non-weight bearingfor at lmst2 months. Qffhepafienfs,11 hada satisfacfoyresult,onepatienthad a fair result withpmisfenfpainand the otherhada poor resultwhen thefixationfailed in a comminufed&icon&v fracture in poroficbone. This technique is minimally invasive and avoids many of the complicationsof both consewafive and operativetreafmentand will have an expanding role to play in fhe managementof thesefractures.
Introduction Minimally invasive techniques are being developed and utilized in all branches of surgery. The advantages of reduced morbidity and decreased hospital stay are well documented. Closed reduction and percutaneous pinning has been used in the treatment of selected fractures, in particular intracapsular hip fractures, while arthroscopy is the basic tool in treating all types of internal derangement of the knee and is being employed in many other joints. The use of a combination of these two techniques in the treatment of tibial plateau fractures is not new. A percutaneous fixation technique using a cerclage wire loop was introduced by Landelius in 1939. Rasmussen (1973) reported on 12 patients who had been treated by this method, while Iansinger et al. (1986) detailed the long-term followup (10-20 years) of 14 patients treated in a similar fashion. Jennings (1985) described his experience in using the arthroscope to assist in the treatment of 17 patients with fractures of the tibial plateau. There has otherwise been little attention focused on minimally invasive techniques in tibia1 plateau fractures. This paper reviews the authors’ experience with both of these methods over a d-year period.
Materials and methods During the period December 1986 to December 1990, 13 patients with displaced fractures of the tibial plateau were 0 1992 Butterworth-Heinemann 0020-1383/92/060358-03
Ltd
of Orthopaedics,
St Vincent’s Hospital,
treated by closed reduction and percutaneous screw fixation. The average age was 52 years (range 22-85 years). There were eight maIe and five female patients. The right leg was affected in eight cases and the left in five. The cause of the injury was a road traffic accident in five cases, a fall in five, an accident at work in two and a sporting accident in one. The injury was an isolated event in nine cases. One patient had multiple injuries, while three others had either local abrasions or other minor injuries. There were no open fractures in the series. The fractures were graded using the A0 classification (Table I). Of the patients, 11 were treated by closed reduction, traction ligamentotaxis and percutaneous screw fixation under image intensification (Figures I, 2). In two patients, a percutaneous reduction technique using arthroscopic guidance was employed. The haemarthrosis was lavaged and then the depressed articular surface fragments were elevated with a probe inserted through a cortical window in the proximal tibial metaphysis. The postoperative regimen was individualized depending on the patient’s age, quality of bone and stability of fixation. In general the policy was for early range of motion exercise and non-weight-bearing for a 2-3 month period. Four patients had no postoperative splintage, five had a cylinder cast for 10 days and four had a cast brace for 8 weeks. The patients were reviewed at a mean of 17 months after injury (range 4-54 months). At review, all patients were assessed for pain, range of motion and stability of the knee joint and the final result graded using Rasmussen’s criteria (Rasmussen, 1973) (Table U).
Table 1. Types of fracture Schatzker/AO type I
II
No. of patients 4 7
III IV V VI
-
Total
13
1 1
388
Injury: the British Joumal of Accident Surgery (1992) Vol. 23/No.
6
Figure 1. a, Pre-and b, postoperative radiographs of a type I fracture fixed with percutaneous screws.
Results The average duration of hospitalization was 5 days (range 2-27 days ). The one patient *with prolonged hospital stay (27 days) had multiple injuries. There were no wound infections or deep sepsis but one patient (Case 10) with an ipsilateral fractured femur developed proximal deep venous thrombosis. Radiographs at follow-up did not show any osteoarthritic joint deterioration. Of the 13 patients, II had satisfactory results with no interference at work or recreational activities. One patient had a poor result, an 85-year-old psychogeriatric patient (Case II) who had loss of reduction of a type V fracture. Despite the poor radiological appearance the lady had a stable knee with 90” of knee flexion. One patient with a type II fracture (Case 2) had a fair result. He complained of mild to moderate pain 2 years after his fracture and had not returned to work A total of seven patients required removal of metal because of local discomfort after the fracture had healed. No patient had angular deformity or instability at review and none required late surgery for internal derangement.
Discussion The ideal outcome after a tibia1 plateau fracture is a stable, pain-free non-osteoarthritic lmee joint with a range of motion that is adequate for functional requirements. There is virtual universal agreement that reduction and stabilization of displaced fragments, early mobilization and delayed weight-bearing are necessary to achieve an optimal result; however, controversy exists as to how these aims should be achieved. The debate is divided between two major groups, one favouring non-operative management and the other operative treatment. Non-operative options include traction and early mobilization (Apley, 1979), plaster cast immobilization (Drennan et al., 1979), and cast bracing (Scotland and Wardlaw, 1981) while operative treatment usually comphses open reduction and buttress plating with bone grafting (Schatzker et al., 1979). Difficulties with conservative treatment include inadequate reduction, instability and prolonged hospitalization, while open reduction and internal fixation is a difficult operation, even in experienced hands, requires extensive exposure of the knee joint and is occasionally complicated by infection.
Figure 2. a, preoperative and b postoperative radiographs of a type II fracture. c, Follow-up radiograph at 48 months after
removal of metal.
Reduction by closed ligamentotaxis or assisted by arthroscopy and percutaneous fixation are methods that seek to combine the attributes of both operative and non-operative philosophies while at the same time avoiding the complications of both. They have become feasible alternatives because use of image intensification and cannulated screws allows precise placement of the fixation device. The indications for this type of surgery, in our opinion, are fractures where there is a large peripheral fragment, i.e. types I, II, and IV. Pure plateau depression fractures, type III, or comminuted fractures, types V and VI, are not suitable for these minimally invasive methods. The only technical failure in this series occurred in a type V fracture. Reduction and stabilization of the displaced condyle allows the meniscus to resume its weight-bearing function, particularly on the lateral side (Walker and E&man, 1975) Indeed, preservation of the meniscus explains why good functional results can be obtained even with poor radiographic appearances. Our experience with these methods is limited and the follow-up is short, but nevertheless we have been encouraged by our results; 11 of 13 patients had a satisfactory result which is similar to those reported by Lansinger et al., (1986) - 13 satisfactory out of 14, and Duwelius and Connolly (1988) who had satisfactory results in all 12 of their patients. We believe that percutaneous screw fixation and arthroscopy will both have an expanding role to play in the management of tibial plateau fractures and will reduce the indications for open reduction.
Keogh et al.: Percutaneous screw fixation of tibia1 plateau fractures
389
Table II. Rasmussen’s criteria for functional grading of outcome Satisfactory Points Objective complaints Pain No pain Occasional ache, bad weather pain Stabbing pain in certain positions Afternoon pain, intense, constant pain around knee after activity Night pain at rest Walking capacity Normal walking capacity (in relation to age) Walking outdoors at least 1 h Short walks outdoors 15 min. Walking indoors only Wheelchair/bedridden
Unsarisfac~ory
Excalien t
Good
Fair
Poor
5
4
2
2
27
20
10
6
6 5 4
Clinical signs
a. Extension Normal Lack of extension (O-l 0) Lack of extension( > 10) b. Total range of motion At least 140 At least 120 At least 90 At least 60 At least 30 0 c. Stability Normal stability in extension and 20” of flexion Abnormal instability 20” of flexion Instability in extension 10 Instability in extension 10
6 4 2
6 5 4 2
Table III. Results by Rasmussen’s criteria Case No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Age M.W. T.O’S M.R. N.A. C.McC, L.B. S.B. T.M. J.O’C. F.O’K. E.D. H.M. J.McC.
60 56 46 55 54 53 22 42 33 32 85 77 58
Fracture we I II II II II II IV (medial) I I II V (bicondylar) II I
Follow-up (months)
Complications
Outcome
27 54 16 17 17. 48 28 9 8 7 10 7 9
DVT Loss of fixation -
Ex: Fair Ex. Ex. Ex. Ex. Ex. Ex. Ex. Ex. Poor Ex. Ex.
“Ex. = excellent
References Apley A. G. (1979) Fractures of the tibial plateau. Orfhop. Clin. No&
Am. 10,61.
Drennan D. B., Lecher F. and Maylahn D. (1979) Fractures of the tibia1 plateau: treatment by closed reduction and spica cast. J Bone]oinf Surg. 61A, 989. Duwelius P. J. and Connolly J. F. (1988) Closed reduction of tibia1 plateau fractures. A comparison of functional and roentgenographic end results. C/in. Orfhop. 230, 117. Jennings J. E. (1985) Arthroscopic management of tibia1 plateau fractures. Arfhroscopy l(3), 160. Lansinger O., Bergman B., Komar L. et al. (1986) Tibial condylar fractures. A twenty year follow-up. J BoneJoint Surg. 68A, 13.
P. S. (1973) Tibial condylar fractures. Impairment of knee joint stability as an indication for surgical treatment. J Both Joint Surg. 55A, 1331. Schatzker J., McBroom R. and Bruce D. (1979) The tibial plateau fracture: the Toronto experience. Ckrz. Or&p. 138,94. Scotland T. and Wardlaw D. (1981) The use of cast-bracing as treatment for fractures of the tibial plateau. 1. Bone Joint Strrg Rasmussen
63B, 575.
Walker P. S. and Erkman M. J. (1975) The role of the menisci in force kansmission across the knee. Ckn. Orfhop. 109, 184. Paper accepted 27 November
1991.
Requests for rep’nfs shod be aaldresed to: Mr P. Keogh, 18 Lansdowne Village, Sandymount, Dublin 4, Ireland.
23,
(6), 388-390
387
Printed in Great Britain
Percutaneous screw fixation of tibia1 plateau
fractures P. Keogh’, C. KellyI, W. F. Cashmanl, A. J. McGuinness’ and S. K. O’RourkeZ ‘Department of Orthopaedics, Dublin, Ireland
Cork Regional Hospital, Cork and “Department
A seriesof 13 patientswith dispLxedfia&res of the tibia1plateautreated by closed reductionand percutaneouspinning have been reviewed 77 months affer surgery. All fhe operationswere pe@rmed using image infensificafion to aid reducton of fhefra&re by ligamentotaxis and foguide screw placement. In two CASPS, arthroscopy was used in addition to fan’litafeelevationof the ark&r surfacetcsinga probe inset-fed througha wrtical window in the proximal tibkl metaphysis. The postoperative rehabilitationprogramme consistedof early mobilizafionand non-weight bearingfor at lmst2 months. Qffhepafienfs,11 hada satisfacfoyresult,onepatienthad a fair result withpmisfenfpainand the otherhada poor resultwhen thefixationfailed in a comminufed&icon&v fracture in poroficbone. This technique is minimally invasive and avoids many of the complicationsof both consewafive and operativetreafmentand will have an expanding role to play in fhe managementof thesefractures.
Introduction Minimally invasive techniques are being developed and utilized in all branches of surgery. The advantages of reduced morbidity and decreased hospital stay are well documented. Closed reduction and percutaneous pinning has been used in the treatment of selected fractures, in particular intracapsular hip fractures, while arthroscopy is the basic tool in treating all types of internal derangement of the knee and is being employed in many other joints. The use of a combination of these two techniques in the treatment of tibial plateau fractures is not new. A percutaneous fixation technique using a cerclage wire loop was introduced by Landelius in 1939. Rasmussen (1973) reported on 12 patients who had been treated by this method, while Iansinger et al. (1986) detailed the long-term followup (10-20 years) of 14 patients treated in a similar fashion. Jennings (1985) described his experience in using the arthroscope to assist in the treatment of 17 patients with fractures of the tibial plateau. There has otherwise been little attention focused on minimally invasive techniques in tibia1 plateau fractures. This paper reviews the authors’ experience with both of these methods over a d-year period.
Materials and methods During the period December 1986 to December 1990, 13 patients with displaced fractures of the tibial plateau were 0 1992 Butterworth-Heinemann 0020-1383/92/060358-03
Ltd
of Orthopaedics,
St Vincent’s Hospital,
treated by closed reduction and percutaneous screw fixation. The average age was 52 years (range 22-85 years). There were eight maIe and five female patients. The right leg was affected in eight cases and the left in five. The cause of the injury was a road traffic accident in five cases, a fall in five, an accident at work in two and a sporting accident in one. The injury was an isolated event in nine cases. One patient had multiple injuries, while three others had either local abrasions or other minor injuries. There were no open fractures in the series. The fractures were graded using the A0 classification (Table I). Of the patients, 11 were treated by closed reduction, traction ligamentotaxis and percutaneous screw fixation under image intensification (Figures I, 2). In two patients, a percutaneous reduction technique using arthroscopic guidance was employed. The haemarthrosis was lavaged and then the depressed articular surface fragments were elevated with a probe inserted through a cortical window in the proximal tibial metaphysis. The postoperative regimen was individualized depending on the patient’s age, quality of bone and stability of fixation. In general the policy was for early range of motion exercise and non-weight-bearing for a 2-3 month period. Four patients had no postoperative splintage, five had a cylinder cast for 10 days and four had a cast brace for 8 weeks. The patients were reviewed at a mean of 17 months after injury (range 4-54 months). At review, all patients were assessed for pain, range of motion and stability of the knee joint and the final result graded using Rasmussen’s criteria (Rasmussen, 1973) (Table U).
Table 1. Types of fracture Schatzker/AO type I
II
No. of patients 4 7
III IV V VI
-
Total
13
1 1
388
Injury: the British Joumal of Accident Surgery (1992) Vol. 23/No.
6
Figure 1. a, Pre-and b, postoperative radiographs of a type I fracture fixed with percutaneous screws.
Results The average duration of hospitalization was 5 days (range 2-27 days ). The one patient *with prolonged hospital stay (27 days) had multiple injuries. There were no wound infections or deep sepsis but one patient (Case 10) with an ipsilateral fractured femur developed proximal deep venous thrombosis. Radiographs at follow-up did not show any osteoarthritic joint deterioration. Of the 13 patients, II had satisfactory results with no interference at work or recreational activities. One patient had a poor result, an 85-year-old psychogeriatric patient (Case II) who had loss of reduction of a type V fracture. Despite the poor radiological appearance the lady had a stable knee with 90” of knee flexion. One patient with a type II fracture (Case 2) had a fair result. He complained of mild to moderate pain 2 years after his fracture and had not returned to work A total of seven patients required removal of metal because of local discomfort after the fracture had healed. No patient had angular deformity or instability at review and none required late surgery for internal derangement.
Discussion The ideal outcome after a tibia1 plateau fracture is a stable, pain-free non-osteoarthritic lmee joint with a range of motion that is adequate for functional requirements. There is virtual universal agreement that reduction and stabilization of displaced fragments, early mobilization and delayed weight-bearing are necessary to achieve an optimal result; however, controversy exists as to how these aims should be achieved. The debate is divided between two major groups, one favouring non-operative management and the other operative treatment. Non-operative options include traction and early mobilization (Apley, 1979), plaster cast immobilization (Drennan et al., 1979), and cast bracing (Scotland and Wardlaw, 1981) while operative treatment usually comphses open reduction and buttress plating with bone grafting (Schatzker et al., 1979). Difficulties with conservative treatment include inadequate reduction, instability and prolonged hospitalization, while open reduction and internal fixation is a difficult operation, even in experienced hands, requires extensive exposure of the knee joint and is occasionally complicated by infection.
Figure 2. a, preoperative and b postoperative radiographs of a type II fracture. c, Follow-up radiograph at 48 months after
removal of metal.
Reduction by closed ligamentotaxis or assisted by arthroscopy and percutaneous fixation are methods that seek to combine the attributes of both operative and non-operative philosophies while at the same time avoiding the complications of both. They have become feasible alternatives because use of image intensification and cannulated screws allows precise placement of the fixation device. The indications for this type of surgery, in our opinion, are fractures where there is a large peripheral fragment, i.e. types I, II, and IV. Pure plateau depression fractures, type III, or comminuted fractures, types V and VI, are not suitable for these minimally invasive methods. The only technical failure in this series occurred in a type V fracture. Reduction and stabilization of the displaced condyle allows the meniscus to resume its weight-bearing function, particularly on the lateral side (Walker and E&man, 1975) Indeed, preservation of the meniscus explains why good functional results can be obtained even with poor radiographic appearances. Our experience with these methods is limited and the follow-up is short, but nevertheless we have been encouraged by our results; 11 of 13 patients had a satisfactory result which is similar to those reported by Lansinger et al., (1986) - 13 satisfactory out of 14, and Duwelius and Connolly (1988) who had satisfactory results in all 12 of their patients. We believe that percutaneous screw fixation and arthroscopy will both have an expanding role to play in the management of tibial plateau fractures and will reduce the indications for open reduction.
Keogh et al.: Percutaneous screw fixation of tibia1 plateau fractures
389
Table II. Rasmussen’s criteria for functional grading of outcome Satisfactory Points Objective complaints Pain No pain Occasional ache, bad weather pain Stabbing pain in certain positions Afternoon pain, intense, constant pain around knee after activity Night pain at rest Walking capacity Normal walking capacity (in relation to age) Walking outdoors at least 1 h Short walks outdoors 15 min. Walking indoors only Wheelchair/bedridden
Unsarisfac~ory
Excalien t
Good
Fair
Poor
5
4
2
2
27
20
10
6
6 5 4
Clinical signs
a. Extension Normal Lack of extension (O-l 0) Lack of extension( > 10) b. Total range of motion At least 140 At least 120 At least 90 At least 60 At least 30 0 c. Stability Normal stability in extension and 20” of flexion Abnormal instability 20” of flexion Instability in extension 10 Instability in extension 10
6 4 2
6 5 4 2
Table III. Results by Rasmussen’s criteria Case No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Age M.W. T.O’S M.R. N.A. C.McC, L.B. S.B. T.M. J.O’C. F.O’K. E.D. H.M. J.McC.
60 56 46 55 54 53 22 42 33 32 85 77 58
Fracture we I II II II II II IV (medial) I I II V (bicondylar) II I
Follow-up (months)
Complications
Outcome
27 54 16 17 17. 48 28 9 8 7 10 7 9
DVT Loss of fixation -
Ex: Fair Ex. Ex. Ex. Ex. Ex. Ex. Ex. Ex. Poor Ex. Ex.
“Ex. = excellent
References Apley A. G. (1979) Fractures of the tibial plateau. Orfhop. Clin. No&
Am. 10,61.
Drennan D. B., Lecher F. and Maylahn D. (1979) Fractures of the tibia1 plateau: treatment by closed reduction and spica cast. J Bone]oinf Surg. 61A, 989. Duwelius P. J. and Connolly J. F. (1988) Closed reduction of tibia1 plateau fractures. A comparison of functional and roentgenographic end results. C/in. Orfhop. 230, 117. Jennings J. E. (1985) Arthroscopic management of tibia1 plateau fractures. Arfhroscopy l(3), 160. Lansinger O., Bergman B., Komar L. et al. (1986) Tibial condylar fractures. A twenty year follow-up. J BoneJoint Surg. 68A, 13.
P. S. (1973) Tibial condylar fractures. Impairment of knee joint stability as an indication for surgical treatment. J Both Joint Surg. 55A, 1331. Schatzker J., McBroom R. and Bruce D. (1979) The tibial plateau fracture: the Toronto experience. Ckrz. Or&p. 138,94. Scotland T. and Wardlaw D. (1981) The use of cast-bracing as treatment for fractures of the tibial plateau. 1. Bone Joint Strrg Rasmussen
63B, 575.
Walker P. S. and Erkman M. J. (1975) The role of the menisci in force kansmission across the knee. Ckn. Orfhop. 109, 184. Paper accepted 27 November
1991.
Requests for rep’nfs shod be aaldresed to: Mr P. Keogh, 18 Lansdowne Village, Sandymount, Dublin 4, Ireland.
